Tarsal decancellation in the residual resistant arthrogrypotic clubfoot

Abstract

Introduction: Conservatism is well recognised after Ponseti's method in the treatment of congenital clubfoot; however, this is not applicable to the complex and resistant arthrogrypotic type which challenges the orthopaedic surgeon. In such a type, soft tissue releases as fasciotomies, tenotomies, and capsulotomies, as well as osteotomies are insufficient, and joint fusions are not suitable in early childhood before skeletal maturity.

Patients and methods: Twelve children (15 feet) with residual resistant arthrogrypotic clubfeet between 2-4 years of age were analysed clinically and radiographically. All of the cases received previous conservative Ponseti's method of treatment in their first year of life followed by soft tissue releases (plantar fasciotomy, posteromedial tenotomies, capsulotomies, and abductor hallucis release) before treatment by decancellation of the cuboid, the calcaneus, and the talus to correct the complex adduction, supination, varus, and equinus deformities. Pre-operative measurements of certain foot angles were compared with their corresponding postoperative values.

Results: A grading scheme for evaluation of the results using a point scoring system was suggested to evaluate accurately both clinical and radiographic results after a follow-up period of an average of 3.3 years. Six feet (40%) had excellent, six (40%) good, three (20%) fair, and no poor (0%) outcome. There was no major complication. There was significant improvement in the result (P > 0.035).

Conclusions: Tarsal decancellation is particularly applicable to residual resistant clubfoot such as the arthrogrypotic type at an early age. It shortens the period of disability, improves the range of foot motion, and does not interfere with the foot bone growth.

Figure 1

The components of the deformity: the forefoot cavus (left), the forefoot adduction (middle), the hindfoot varus (middle), and the ankle equinus (right).

Figure 2

The adduction, varus, and equinus position, and the small calf.

Figure 3

Operative technique: (A) skin incision (above); (B) punctures in the three tarsal bones (the cuboid, the calcaneus, and the talus) (middle right & left); (C) manipulative correction after decancellation (below).

Figure 4

Pre- and postoperative clinical examinations. Pre-operative bilateral feet deformity (above): (A) from in front (above right), and (B) from behind (above left). Postoperative bilateral feet correction of deformity (middle and below): (C) from in front (middle right), (D) from behind (middle left), and (E) from the plantar aspect (below).

Figure 5

Pre- and postoperative angle measures. Pre-operative angle measures (above): (A) anteroposterior view (above, left): TCA1 0°, TFMA1 70°, CFMA 45°; (B) lateral view (above, right): TibCA 100°, TCA2 28°, TFMA2 15°. Postoperative angle measures (below): (C) anteroposterior view (below, left): TCA1 35°, TFMA1 10°, CFMA 18°; (D) Lateral view (below, right): TibCA 80°, TCA2 35°, TFMA2 10°.